Consent For Treatment Of A Minor

Smiles on Trindle Dental Care

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State Law Requires us to obtain parental consent for dental treatment of a minor. Please read this form carefully and ask about anything you do not understand.

In general terms, the dental treatment may or may not include the following:

  • Radiographs (x-rays) of teeth and jaw
  • Cleaning and fluoride treatment
  • Sealants
  • Fillings (will be discussed with parent prior to scheduling, verbal consent at appointment required)
  • Crowns (will be discussed with parent prior to scheduling, verbal consent at appointment required)
  • Extractions (will be discussed with parent prior to scheduling, verbal consent at appointment required)

Although their occurrence is not frequent, some risks and complications are known to be associated with dental or oral surgery procedures. The most common complications associated with pediatric dental treatment include: nausea following the administration of topical fluoride and children biting and injuring the tongue or lip following the administration of local anesthesia. Less common complications include the risk of numbness, infection, swelling, prolonged bleeding, discoloration, vomiting, allergic reactions, injury to the tongue and/or lips, and damage to and possible loss of existing teeth and/or restorations (fillings). For children with heart disease, the risk of bacterial infection of the heart following dental treatment exists; therefore, antibiotics may be prescribed before to minimize the risk.

Minor Child

Parent/Legal Guardian

I hereby state that I have read and understand this consent form. I hereby authorize the doctor and/or dental auxiliaries at Smiles on Trindle Dental Care to perform dental treatment on my child.

****I agree to accompany my child to all dental visits unless he/she is the age of 13 or older.****

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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